35-159 w The Commonwealth of Massachusetts
Department of Industrial Accidents
- 4 Office of Investigations
E 600 Washington Street
,J , -^—y Boston,MA 02111
f 4l
�= www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): O A,f ` n C !-Vm iDi-o\,YMe,
Address: V---"N Q
City/State/Zip: Qlj�� 1 QC 0 4hone
Are you an employer?Check the appropriate box: Type of project(required):
1.M I am a employer with �� 4. 0 I am a general contractor and I 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole propri etor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working or me in, capacity. employees and have workers'
g y p ty 9. []Building addition
[No workers' comp.insurance comp.insurance.t
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LF0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13yOther I t1 Su�a—� �'1
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site
inforination. h
Insurance Company Name:
_ (�('-�\G�.
Policy#or Self-ins. Lic.#: ov�)CD c 0'2- Expiration Date: 8
Job Site Address: 70 k,L R�_ City/State/Zip: MA
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify r - the pains a,d penalft�i perjury that the inf®rmadon provided above is trace and correct
t ( ! ,4 4 Date: 7 9/1,
Signature: �` � , 1;�-�,
Phonff.
Official use only. Do not write in this arena,to be completed by city or town official
City or Town: Perm t/Lieense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town.Clerk 4.Electrical Inspector S.plumbing Inspector
6. Other
Contact Person: Phone#:
Cif' of Northampton 212 Main Street, Northampton, MA 0106D
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 7(ol '/Rq '1 Rd.
The debris will be transported by: A kmcc i rnprt�l�m�c1`�
The debris will be received by: `MDA 'Re-ggcI tnr1
Building permit number:
Name of Permit Applicant c �`m2
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: ( Not Applicable 11 Name of License Holder: `56n ti ` 0(0 b—aco
vQ�IQ� f1u �l-4•���}e,M etZ� .ZL License Number
P o Pxx tcOCo2� fore r ��
0\0 162 R[-2-L116
Address Expiration Date
Ck G-5bt-1-1 SZZ
5ignatur Telephone
9.Re isteied Homeam rovement Contractor Not Applicable ❑
akm Twvpnxmen� ��
Company Nlafne Registration Number
Y , 7-� aC) I I - � )-1 11�0
Address �n Expiration Date
A— Telephone��2J"UC��'�c��Z
SECTION 16-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25.C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.' .
Signed Affidavit Attached Yes....... No::.... ❑
ion
The current exemption for"homeowners"was c-,tended to include Owner-c,ccrr-TT elltta�s of one(I) or two(2)farniiies
and to allow such homeowner to engage an individual for hire who does not possess a license,proAded that the c�`�rt er acts
as saapervisor.CAIR 980E Sixth Edition Section
(Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A bersom whe constructs more than one home in a two-year per-iod shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official. that he/she shall be
respomsible for all such work performed under the bu lcun gr permit.
As acting Construction Supervisor your presence on the j ob site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be adNised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you tra-y be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Si-nature
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size _.
Frontage _._.....__. .. .... :._....,......_< k ...............__...._.._.._....._...._.. _....__....
Setbacks Front
_._._... _.,.._. .....
Side L::. _...__. R:<..__._....: L:'......._...... R:<.........
....
Rear
Building Height _._.._.,._..
Bldg. Square Footage _.,.....:. %
Open Space Footage o _._._...
(Lot area minus bldg&paved I.
4 of Parking Spaces _.._..._..: v.,.
.......... _.._._ __.... ....
Fill:
volume&Location) ___.._..:......___._.._._._.._.._. ._._...._----.--::._..._....._..__.....__ ..___._---
A. Has a Special Permit/Variance/FiQdingAver been issued for/on.the site?
NO 0 DON'T KNOW YES Q
IF YES, date issued:'w "
IF YES: Was the permit recorded at the Registry of Deeds?
hits DONT KNONY � YES
iF YES: enter Book Pages :end/or Document#
B. Does the site contain a brook, body of water or wetlands?. NO XXV DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
disturb i ,,sri a' t' r ,t )over Scre or!c t ela a
E. i/viil life Cbt"IStri!CiiUYt activity Ul�ll.fr�! �O�c�[tri�S,grn�[I i c;: Ve,.€Orl,0, t,l,i;1`J� �,V.., t_,., of Oi On"triFcOn plan
that will disturb over 1 sere? YES N0
IF YES,then a Northampton Storm water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks ([] Siding[0] her
Brief Descriptiop of Proposed
Tn 1-2 0 1 c6e a4lc w q ceil oe>s- bn bevek +b'VZ491 In3infi ,pl)ie vcn-fs
Work: � `l t Ffr !Q 1 i vl�c � nvr t,�ttts �.v�celf��se,,
Qrr seat-t-
Alteration of existing bedroom Yes No Adding new bedroom Yes No L,;_e,, ,o-cz111_1
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a..@f New house aiid or addiitl0 i.fb exist1h9 hQQSIi 9, 'Ohlmfat6 ih e fou6 WECag:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize 1\�P—`SL�n bw,to act on my Vehalf,in all matters relative to work autho ' ed by this building permit application.
Signatu of Owner Date
0LAt e_ err— ...-r4,rA Cerlc- as Owner/Authorized
L;oe1zt hereby declare inat'Uhe and cn the fcrego!nrt-inpficntlon are true and accurate,to the bast of my knowledge i
j and bslief.
I Signed under the pains and penalties of perjury.
�!1�tA50� c�\ tai
Print Nara
X06 7 8 I.5
Signature df OA er/Agent Dale
L7il rt�F1I1t�7tD 1T
a gga C4 U S rt tB
�t DEPARTMENT OF BUILD/NC, INSPECTIONS
212 Main Street . Municipal Huilding
Northampton, MA 01060
LOUISHASBROUCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21,2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1't floor
.30 2°d floor
•20 " 1A floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with,a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6/K of estimated cost
TENTS $25.00
-ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1(1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
*Filing deadline Is 12:00 pm(noon)on Wednesday.
Depotment use only
City of Northampton Status of Permit
L �Building Department Curb CutlDnveway Permit
L ' 20� 212 Main Street Sewer/Septic AvailablitROOM 100 WaterNVellAvailability rtham ton, MA 01060 Gas Inspec p ton,v1 ® 587-1240 Fax 413-587-1272 Plot/Site"Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: s This section to be completed by office
7Q JR�t1 �(Jl Map Lot Unit
Florence IkO 0l0(o vL- Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
K h nt n RAt t 5hon 7(i7 /2 n Flc>rence tit,/4 ot4�e
Name(Print) Curre ailing dr s:
t V%3 �- 0587
Telephone
Signature
.2 Authorized Agent:
2�SM t t6 Valt Name n 0em Q Rlv r �c�e. Flvr ��,4-0�cx�
N`056(Pri ) Current Mailing Address:
eq
q13 5-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building J� (a)Building Permit FeS-600. UU
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File 4 BP-2016-0135
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 767 RYAN RD
MAP 35 PARCEL 159 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_vpeof Construction: INSTALL ATTIC&WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106006
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
e "eellay
i re of B it m ffi g O ial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
767 RYAN RD BP-2016-0135
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 159 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0135
Project# JS-2016-000226
Est. Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 106006
Lot Size(sq. ft.): 1045440.00 Owner: MATRISHON JOSEPH M&MICHAEL J&JOHN R
zoniny: Applicant: VALLEY HOME IMPROVEMENT INC
AT. 767 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.81312015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC & WALL INSULATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType• Date Paid: Amount:
Building 8/3/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner